Healthcare Provider Details

I. General information

NPI: 1255911681
Provider Name (Legal Business Name): JESSICA FLESER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 08/24/2024
Certification Date: 08/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E BELTLINE AVE NE STE 100
GRAND RAPIDS MI
49506-1214
US

IV. Provider business mailing address

1257 APPLE CREEK DR SE
GRAND RAPIDS MI
49546-8268
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax:
Mailing address:
  • Phone: 616-822-9390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361007721
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: